Randomized trial of depression follow-up care by online messaging

Quality of antidepressant treatment remains disturbingly poor. Rates of medication adherence and follow-up contact are especially low in primary care, where most depression treatment begins. Telephone care management programs can address these gaps, but reliance on live contact makes such programs less available, less timely, and more expensive.

Evaluate the feasibility, acceptability, and effectiveness of a depression care management program delivered by online messaging through an electronic medical record.

Randomized controlled trial comparing usual primary care treatment to primary care supported by online care management

Nine primary care clinics of an integrated health system in Washington state

Two hundred and eight patients starting antidepressant treatment for depression.

Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.

An online survey approximately five months after randomization assessed the primary outcome (depression severity according to the Symptom Checklist scale) and satisfaction with care, a secondary outcome. Additional secondary outcomes (antidepressant adherence and use of health services) were assessed using computerized medical records.

Patients offered the program had higher rates of antidepressant adherence (81% continued treatment more than 3 months vs. 61%, p = 0.001), lower Symptom Checklist depression scores after 5 months (0.95 vs. 1.17, p = 0.043), and greater satisfaction with depression treatment (53% "very satisfied" vs. 33%, p = 0.004).

The trial was conducted in one integrated health care system with a single care management nurse. Results apply only to patients using online messaging.

Our findings suggest that organized follow-up care for depression can be delivered effectively and efficiently through online messaging.